Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, the facility did not promptly report two separate incidents of resident-to-resident abuse to the appropriate state authorities. In the first incident, two residents engaged in a physical altercation in the smoking area, with both residents exchanging slaps and falling to the ground. Staff intervened, redirected the residents, and assessed for injuries, but the event was not reported to the state agency within the required timeframe. In the second incident, a resident with a history of behavioral issues and multiple psychiatric diagnoses kicked another resident multiple times during breakfast. The incident was documented by nursing staff and reported internally to the DON, but again, the required immediate external reporting to the state agency did not occur. The resident who was kicked had severe cognitive impairment and required substantial assistance with transfers. Interviews with staff and residents confirmed the altercations and the behavioral history of the resident involved in both incidents. Record reviews and staff interviews further revealed that the facility was aware of the behavioral risks associated with the resident involved in both incidents, including previous altercations, psychiatric hospitalizations, and unsuccessful attempts to secure alternative placement. Despite these known risks and the facility's policy requiring immediate reporting of abuse allegations, the facility did not follow established procedures to notify the state agency within the mandated timeframe for either incident.